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    <ul>
        
                    
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_statement.aspx")%>">
        Plan Statement</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_certificate.aspx")%>">
        Plan Certificate</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_terminate.aspx")%>">
        Terminate / Renew</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_claim.aspx")%>">
        Claim Instructions</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/insurance_home.aspx")%>">Plan
        Details</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_apply_hospital.aspx")%>">
        Apply For Hospitalisation Plan</a></li>
    <li><a href="<%= Page.ResolveUrl("~/product/insurance/user/insurance_apply_accident.aspx")%>">
        Apply For Personal Accident Plan</a></li>
    </ul>


</asp:Content>


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fieldset
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    border:0;
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h5
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    font-size:1.8em;border: 1px solid #FA5882;background-color : #FA5882;color: White;width: 750px; 
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    <h1 style="font-size: 2.0em; text-transform: none; font-weight: 900; font-family: Andalus;">
        Power Saver Hospitalisation Online Application</h1>
<p>
        &nbsp;</p>
    <p>
        Power Saver Hospitalisation is exclusively tailored to fit your budget without compromising
        on the health protection for you & your loved ones..View plan details. Please refer
        to the terms and conditions before filling out this application.</p>
    <p>
        To be eligible:</p>
    <p>
        1. (a) Adults from 18 to 65 years old (age at next birthday). Policy renewable
    up to age 80 (age at next birthday) subject to yearly review. <br /><br />
        (b) Children from 15 days old to 18 years old (age at next birthday). Policy renewable
        up to age 25 (age at next birthday) if he / she is enrolled in an educational institution
        on full-time higher education (and not in full-time national service).<br />
        <br />

    <p>
        Singapore Citizens, Permanent Residents of Singapore, Employment Pass Holders, Student
        Pass Holders, Dependant Pass Holders or Work Permit Holders.
        <br />
        <br />
        Employment Pass Holders, Student Pass Holders, Dependant Pass Holders and Work Permit
        Holders must supply a copy of their respective pass or work permit and a bona fide
        residential address in Singapore.
    </p><br />
    <p>2. Proposal for children must include at least one parent.</p>
    <p>
        &nbsp;</p>
     <h5>Particulars of Personal to be Insured</h5>
    <fieldset>
        <legend></legend>
        <table id="gg_app_parent">
            <tr>
                <td class="appFormFont">
                    First name:
                </td>
                <td>
                    <asp:TextBox ID="tb_firstName" runat="server" Enabled="False" ></asp:TextBox>
                </td>
                <td class="appFormFont">
                    Last name:
                </td>
                <td>
                    <asp:TextBox ID="tb_lastName" runat="server" Enabled="False"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    NRIC:
                </td>
                <td>
                    <asp:TextBox ID="tb_nric" runat="server" Style="margin-left: 0px" Width="125px" 
                       Enabled="False"></asp:TextBox>
                </td>
                <td class="appFormFont">
                    Nationality:
                </td>
                <td>
                    <asp:TextBox ID="tb_nationality" runat="server" Enabled="False"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    Gender:
                </td>
                <td>
                    <asp:RadioButton ID="rb_male" runat="server" Text="Male" GroupName="gender" 
                        Enabled="False"/>
                    &nbsp;<asp:RadioButton ID="rb_female" runat="server" Text="Female" 
                        GroupName="gender" Enabled="False"/>
                </td>
                <td class="appFormFont">
                    Marital status:
                </td>
                <td>
                    <asp:DropDownList ID="ddl_maritalStatus" runat="server">
                        <asp:ListItem>Single</asp:ListItem>
                        <asp:ListItem>Married</asp:ListItem>
                        <asp:ListItem>Widowed</asp:ListItem>
                        <asp:ListItem>Divorced</asp:ListItem>
                    </asp:DropDownList>
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    Date of Birth:
                </td>
                <td>
                    <asp:TextBox ID="tb_dob" runat="server" TextMode="SingleLine" Enabled="False"></asp:TextBox>
                </td>
                <td class="appFormFont">
                    Occupation:
                </td>
                <td>
                    <asp:TextBox ID="tb_occupation" runat="server"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_occupation" runat="server" ControlToValidate="tb_occupation" ErrorMessage="Please input the Occupation" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    Relationship to the person to be insured:
                </td>
                <td>
                    <asp:TextBox ID="tb_relationship" runat="server" Enabled="False">SELF</asp:TextBox>
                    <asp:RequiredFieldValidator ID="rd_raleationShip" runat="server" ControlToValidate="tb_relationship" ErrorMessage="Please input raleation ship"></asp:RequiredFieldValidator>
                </td>
                <td />
                <td />
            </tr>
            <tr>
                <td class="appFormFont">
                    Tel(H):
                </td>
                <td>
                    <asp:TextBox ID="tb_tel" runat="server" ></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_tel" runat="server" ControlToValidate="tb_tel" ErrorMessage="Please input tel number" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
                <td class="appFormFont">
                    Mobile:
                </td>
                <td>
                    <asp:TextBox ID="tb_mobile" runat="server" ></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_mobile" runat="server" ControlToValidate="tb_mobile" ErrorMessage="Please input Mobile" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    Email:
                </td>
                <td>
                    <asp:TextBox ID="tb_email" runat="server"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_email" runat="server" ControlToValidate="tb_email" ErrorMessage="Please input Email" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
                <td colspan="2">
                </td>
            </tr>
            <tr>
                <td class="appFormFont">
                    Mailing Address:
                </td>
                <td>
                    <asp:TextBox ID="tb_mailingAddress" runat="server" Width="289px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_mailingAddress" runat="server" ControlToValidate="tb_mailingAddress" ErrorMessage="Please input Mailling Address" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
                <td class="appFormFont">
                    Postal code:
                </td>
                <td>
                    <asp:TextBox ID="tb_postal" runat="server"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_postal" runat="server" ControlToValidate="tb_postal" ErrorMessage="Please input postal code" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
               
                <td  colspan ="4">
                     If you are foreigner,please upload a copy of your respective pass or work 
                    permit.&nbsp;</td>
            </tr>
            <tr>
               
               
                <td  colspan = "4">
                    <asp:FileUpload ID="fu_doc" runat="server" />&nbsp;</td>
             
            </tr>
        </table>
    </fieldset>
    <h5>Particulars of Family Members to be Insured</h5>
    
    <fieldset>
    <legend><asp:CustomValidator ID="vd_family" runat="server" ErrorMessage=" Please input full information" ForeColor="Red" OnServerValidate="vd_family_ServerValidation"></asp:CustomValidator></legend>
        <table >
            <tr>
                <td>
                    &nbsp;</td>
                <td>
                    First name&nbsp;</td>
                <td>
                    Last name</td>
                <td>
                    NRIC/FIN/BC 
                    <br />
                    No.</td>
                <td>
                    Date of birth<br />
                    (dd/mm/yyyy</td>
                <td>
                    Gender</td>
                <td>
                    Height<br />
&nbsp; (m)</td>
                <td>
                    Weight<br />
&nbsp;(kg)</td>
                <td>
                    Smoke<br />
                </td>
            </tr>
            <tr>
                <td>
                    Spouse :</td>
                <td>
                    <asp:TextBox ID="tbs_fname" runat="server" Width="83px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbs_lname" runat="server" Width="72px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbs_nric" runat="server" Width="87px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbs_dob" runat="server" Width="82px"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbs_male" runat="server" Text="Male" GroupName="rbs_gender" />
&nbsp;
                    <br />
                    <asp:RadioButton ID="rbs_female" runat="server" Text="Female" GroupName="rbs_gender" />
                </td>
                <td>
                    <asp:TextBox ID="tbs_height" runat="server" Width="34px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbs_weight" runat="server" Width="33px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbs_smoke" runat="server" Text="Yes" />
                    <br />
                    <asp:RadioButton ID="rbs_nsmoke" runat="server" Text="No" />
                </td>
            </tr>
            <tr>
                <td>
                    Child 1:</td>
                <td>
                    <asp:TextBox ID="tbc1_fname" runat="server" Width="82px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc1_lname" runat="server" Width="71px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc1_nric" runat="server" style="margin-left: 0px" Width="88px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc1_dob" runat="server" Width="84px"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc1_male" runat="server" Text="Male" GroupName="rbc1__gender" />
                    &nbsp;<br />
                    <asp:RadioButton ID="rbc1_female" runat="server" Text="Female" GroupName="rbc1__gender"  />
                </td>
                <td >
                    <asp:TextBox ID="tbc1_height" runat="server" Width="36px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc1_weight" runat="server" Width="32px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc1_smoke" runat="server" Text="Yes" />
                    <br />
                    <asp:RadioButton ID="rbc1_nsmoke" runat="server" Text="No" />
                </td>
            </tr>
            <tr>
                <td>
                    Child 2:</td>
                <td>
                    <asp:TextBox ID="tbc2_fname" runat="server" Width="82px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc2_lname" runat="server" Width="72px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc2_nric" runat="server" Width="88px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc2_dob" runat="server" Width="83px"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc2_male" runat="server" Text="Male" GroupName="rbc2__gender" />
                    &nbsp;<br />
                    <asp:RadioButton ID="rbc2_female" runat="server" Text="Female" GroupName="rbc2__gender" />
                </td>
                <td>
                    <asp:TextBox ID="tbc2_height" runat="server" Width="37px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc2_weight" runat="server" Width="33px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc2_smoke" runat="server" Text="Yes" />
                    <br />
                    <asp:RadioButton ID="rbc2_nsmoke" runat="server" Text="No" />
                </td>
            </tr>
            <tr>
                <td>
                    Child 3:</td>
                <td>
                    <asp:TextBox ID="tbc3_fname" runat="server" Width="83px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc3_lname" runat="server" Width="72px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc3_nric" runat="server" Width="89px"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc3_dob" runat="server" Width="83px"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc3_male" runat="server" Text="Male" GroupName="rbc3__gender" />
                    &nbsp;<br />
                    <asp:RadioButton ID="rbc3_female" runat="server" Text="Female" GroupName="rbc3__gender" />
                </td>
                <td>
                    <asp:TextBox ID="tbc3_height" runat="server" Width="37px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:TextBox ID="tbc3_weight" runat="server" Width="34px" TextMode="SingleLine"></asp:TextBox>
                </td>
                <td>
                    <asp:RadioButton ID="rbc3_smoke" runat="server" Text="Yes" />
                    <br />
                    <asp:RadioButton ID="rbc3_nsmoke" runat="server" Text="No" />
                </td>
            </tr>
            <tr>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
                <td>
                    &nbsp;</td>
            </tr>
        </table>



    </fieldset>
    <h5>Details of Employer</h5>
    <fieldset>
        <legend></legend>

        <table id= "tbl_employerDetail">
            <tr>
                <td>
                    Name of Employer:</td>
                <td>
                    <asp:TextBox ID="tbe_name" runat="server" style="margin-left: 2px"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_employer" runat="server" ControlToValidate="tbe_name" ErrorMessage="Pleaes input Name of Employer" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
                <td>
                    Address of Employer:</td>
                <td>
                    <asp:TextBox ID="tbe_address" runat="server"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_address" runat="server" ControlToValidate="tbe_address" ErrorMessage="Please input Address of Employer" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
                <td>
                    Nature of Employer’s Business:</td>
                <td>
                    <asp:TextBox ID="tbe_business" runat="server"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_business" runat="server" ControlToValidate="tbe_business" ErrorMessage="Pleae input Business" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
        </table>

</fieldset>
<h5>Questionnaire</h5>
<fieldset>
        <legend><asp:CustomValidator ID="vd_illness" runat="server" ErrorMessage=" Please input full information" ForeColor="Red" OnServerValidate="vd_illness_ServerValidate"></asp:CustomValidator>
                    </legend>
 
        <table>
            <tr>
                <td>
                    <asp:Label ID="lbq1_disease" runat="server" Text="1.&nbsp;Has any one of the applicants ever had or been told to have, or currently 
                    undergoing any medical treatment for,ever been treated for, under observation 
                    for,any disease, infirmity, illness or physical defect?"></asp:Label>
                    <br />
                    &nbsp; <br />
                    <asp:Label ID="lbq2_surgical" runat="server" Text="2. &nbsp;Has any one of the applicants ever,<br />(a) had a surgical operation?<br />(b) been advised to have any diagnostic test, hospital confinement or surgical operation which has not yet been performed? "></asp:Label>
                   <br />
                    <br />
                </td>
            </tr>
            <tr>
                <td>
                   
                    If the answer to any of the above questions is YES, please provide details 
                    below. If surgery is undertaken, please provide name/nature of surgical 
                    procedure.<br />
                   
                    <table>
                        <tr>
                            <t>
                                Name of Person<br />
                                (First &amp; Last)</td>
                            <td>
                                Nature of Illness/<br />
&nbsp;Disability</td>
                            <td>
                                Date &amp; Duration of Disability</td>
                            <td>
                                Type &amp; Result of Treatment/ Surgery</td>
                            <td>
                                Name &amp; Address
                                <br />
                                of Doctor, Clinic/Hospital</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tb_name1" runat="server" Width="114px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_nature1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_duration1" runat="server" Width="116px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_result1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_address1" runat="server" Width="124px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tb_name2" runat="server" Width="114px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_nature2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_duration2" runat="server" Width="116px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_result2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_address2" runat="server" Width="123px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tb_name3" runat="server" Width="112px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_nature3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_duration3" runat="server" Width="115px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_result3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_address3" runat="server" Width="121px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tb_name4" runat="server" Width="111px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_nature4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_duration4" runat="server" Width="115px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_result4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tb_address4" runat="server" Width="121px"></asp:TextBox>
                            </td>
                        </tr>
                    </table>
                    <br />
                </td>
            </tr>
            <tr>
                <td>
                    &nbsp;<asp:Label ID="lbq3_declined" runat="server" Text="3.Has any one of the applicants ever,<br />(a) had an Accident or Health insurance policy cancelled or its renewal refused?<br />(b) had a Life, Accident or Health insurance policy declined, postponed, withdrawn or subject to special terms and conditions?<br />(c) made a claim against any Insurer in respect of bodily injury or sickness? "></asp:Label>
                    <br />
                    <br />
                    If the answer to any of the questions is YES, please give details:<br />
                    <asp:CustomValidator ID="vd_declinedHistory" runat="server" ErrorMessage="Pleaes input full information" ForeColor="Red" OnServerValidate="vd_declinedHistory_ServerValidate"></asp:CustomValidator>
                    <br />
                    <table>
                        <tr>
                            <td>
                                Full Name</td>
                            <td>
                                Details</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq3_name1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq3_declinedHistory1" runat="server" Width="268px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq3_name2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq3_declinedHistory2" runat="server" Width="268px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq3_name3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq3_declinedHistory3" runat="server" Width="268px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq3_name4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq3_declinedHistory4" runat="server" Width="267px"></asp:TextBox>
                            </td>
                        </tr>
                    </table>
                    <br />
                    <br />
<asp:Label ID="lbq4_known" runat="server" Text="4. Is there any known or foreseeable need to consult any doctor or other health 
                    professional? "></asp:Label>
                    
                    <br />
                    <br />
                    If YES, please give details:<br />
                    <asp:CustomValidator ID="vd_foresseeable" runat="server" ErrorMessage="Pleaes input full information" ForeColor="Red" OnServerValidate="vd_foresseeable_ServerValidate"></asp:CustomValidator>
                    <br />
                    <table class="style1">
                        <tr>
                            <td>
                                Full Name</td>
                            <td>
                                Details</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq4_name1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq4_foreseeableIllness1" runat="server" Width="264px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq4_name2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq4_foreseeableIllness2" runat="server" Width="266px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq4_name3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq4_foreseeableIllness3" runat="server" Width="265px"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbq4_name4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                    <asp:TextBox ID="tbq4_foreseeableIllness4" runat="server" Width="266px"></asp:TextBox>
                            </td>
                        </tr>
                    </table>
                    <br />
                    <br />
                </td>
            </tr>
            </table>
 
</fieldset> 
<h5>Raised Blood Pressure / Hyperlipidaemia (high cholesterol)</h5>
<fieldset>
<legend> </legend>


    <table>
        <tr>
                <td>
                   
                    <br />
                    Applicable only to applicants who have ever had or been told to have, or 
                    currently undergoing any medical treatment for, ever been treated for, under 
                    observation for, Raised Blood Pressure/ Hyperlipidaemia (high cholesterol).<br />
                    Please provide the latest blood pressure and cholesterol reading and date.<br />
                    <br />
                    A. Raised Blood Pressure<asp:CustomValidator ID="vd_blood" runat="server" ErrorMessage="Pleae input full information" ForeColor="Red" OnServerValidate="vd_blood_ServerValidate"></asp:CustomValidator>
                    <br />
                    <table>
                        <tr>
                            <td>
                                Name of Person<br />
                                (First &amp; Last)</td>
                            <td>
                                Systolic &amp;
                                <br />
                                Diastolic Reading</td>
                            <td>
                                Date of<br />
                                Reading</td>
                            <td>
                                Name &amp; address of Doctor,
                                <br />
                                Clinic/Hospital</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhbp_name1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_reading1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_date1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_address1" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhbp_name2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_reading2" runat="server" style="margin-left: 0px"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_date2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_address2" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhbp_name3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_reading3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_date3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_address3" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhbp_name4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_reading4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_date4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhbp_address4" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                    </table>
                </td>
            </tr>
            <tr>
                <td>
                    B. Hyperlipidaemia (high cholesterol)<asp:CustomValidator ID="vd_hyperlipidaemia" runat="server" ErrorMessage="Please input full Hyperlipidaemia information" ForeColor="Red" OnServerValidate="vd_hyperlipidaemia_ServerValidate"></asp:CustomValidator>
                    <br />
                    <table class="style24">
                        <tr>
                            <td>
                                Name of Person<br />
                                (First &amp; Last)</td>
                            <td>
                                Total Cholesterol Level<br />
                                (Tchol)</td>
                            <td>
                                Date of<br />
                                Reading</td>
                            <td>
                                Name &amp; address of Doctor,
                                <br />
                                Clinic/Hospital</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhc_name1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_level1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_date1" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_address1" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhc_name2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_level2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_date2" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_address2" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhc_name3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_level3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_date3" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_address3" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                <asp:TextBox ID="tbhc_name4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_level4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_date4" runat="server"></asp:TextBox>
                            </td>
                            <td>
                                <asp:TextBox ID="tbhc_address4" runat="server"></asp:TextBox>
                            </td>
                        </tr>
                        <tr>
                            <td>
                                &nbsp;</td>
                            <td>
                                &nbsp;</td>
                            <td>
                                &nbsp;</td>
                            <td>
                                &nbsp;</td>
                        </tr>
                    </table>
                </td>
            </tr>
            </table>


</fieldset>
<h5>Details of Insurance</h5>
<fieldset>
         <legend></legend>
        <table>
            <tr>
                <td>
                    &nbsp;<br />
                    Please enter the start date and end date below. 
                    <br />
                    Period for this policy should be 1 year and the policy is renewable.</td>
            </tr>
            <tr>
                <td>
                    Insurance to commence: From
                    <asp:TextBox ID="tbStartDate" runat="server"></asp:TextBox>
                    to
                    <asp:TextBox ID="tbEndDate" runat="server" ReadOnly="True"></asp:TextBox>
                    <asp:RequiredFieldValidator ID="vd_StartDate" runat="server" ControlToValidate="tbStartDate" ErrorMessage="Pleae input From date" ForeColor="Red"></asp:RequiredFieldValidator>
                </td>
            </tr>
            <tr>
                <td>
                    <table>
                        <tr>
                            <td>
                                &nbsp;</td>
                            <td>
                                Choice of Plan</td>
                            <td>
                                &nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                Person to be Insured</td>
                            <td>
                                <asp:DropDownList ID="ddl_plan" runat="server" >
                                    <asp:ListItem Value="A">Plan A</asp:ListItem>
                                    <asp:ListItem Value="B">Plan B</asp:ListItem>
                                    <asp:ListItem Value="C">Plan C</asp:ListItem>
                                    <asp:ListItem Value="D">Plan D</asp:ListItem>
                                    <asp:ListItem Value="E">Plan E</asp:ListItem>
                                    <asp:ListItem Value="F">Plan F</asp:ListItem>
                                </asp:DropDownList>
                            </td>
                            <td>
                                &nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                Spouse</td>
                            <td>
                                <asp:DropDownList ID="ddl_sPlan" runat="server">
                                    <asp:ListItem Value="A">Plan A</asp:ListItem>
                                    <asp:ListItem Value="B">Plan B</asp:ListItem>
                                    <asp:ListItem Value="C">Plan C</asp:ListItem>
                                    <asp:ListItem Value="D">Plan D</asp:ListItem>
                                    <asp:ListItem Value="E">Plan E</asp:ListItem>
                                    <asp:ListItem Value="F">Plan F</asp:ListItem>
                                </asp:DropDownList>
                            </td>
                            <td>
                                &nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                Child 1</td>
                            <td>
                                <asp:DropDownList ID="ddl_c1Plan" runat="server">
                                    <asp:ListItem Value="A">Plan A</asp:ListItem>
                                    <asp:ListItem Value="B">Plan B</asp:ListItem>
                                    <asp:ListItem Value="C">Plan C</asp:ListItem>
                                    <asp:ListItem Value="D">Plan D</asp:ListItem>
                                    <asp:ListItem Value="E">Plan E</asp:ListItem>
                                    <asp:ListItem Value="F">Plan F</asp:ListItem>
                                </asp:DropDownList>
                            </td>
                            <td>
                                &nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                Child 2</td>
                            <td>
                                <asp:DropDownList ID="ddl_c2Plan" runat="server">
                                    <asp:ListItem Value="A">Plan A</asp:ListItem>
                                    <asp:ListItem Value="B">Plan B</asp:ListItem>
                                    <asp:ListItem Value="C">Plan C</asp:ListItem>
                                    <asp:ListItem Value="D">Plan D</asp:ListItem>
                                    <asp:ListItem Value="E">Plan E</asp:ListItem>
                                    <asp:ListItem Value="F">Plan F</asp:ListItem>
                                </asp:DropDownList>
                            </td>
                            <td>
                                &nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                Child 3</td>
                            <td>
                                <asp:DropDownList ID="ddl_c3Plan" runat="server">
                                   <asp:ListItem Value="A">Plan A</asp:ListItem>
                                    <asp:ListItem Value="B">Plan B</asp:ListItem>
                                    <asp:ListItem Value="C">Plan C</asp:ListItem>
                                    <asp:ListItem Value="D">Plan D</asp:ListItem>
                                    <asp:ListItem Value="E">Plan E</asp:ListItem>
                                    <asp:ListItem Value="F">Plan F</asp:ListItem>
                                </asp:DropDownList>
                            </td>
                            <td>
                                &nbsp;</td>
                        </tr>
                    </table>
                </td>
            </tr>
            <tr>
                <td>
                    &nbsp;
                </td>
            </tr>
        </table>

</fieldset>
<h5>Payment Method</h5>
<fieldset>
        <legend></legend>
        <table>
            <tr>
                <td>
                    Please charge the annual premium
                  
                    &nbsp;<asp:DropDownList ID="ddlPaymentMethod" runat="server">
                        <asp:ListItem>Monthly</asp:ListItem>
                        <asp:ListItem>Yearly</asp:ListItem>
                    </asp:DropDownList>
                    &nbsp;to my Power Save Account.
                </td>
            </tr>
            <tr>
                <td>
                    &nbsp;
                </td>
            </tr>
            <tr>
                <td><asp:CheckBox ID="cbAgree" runat="server" 
                        
                        Text="I have read and understand and agree the terms and conditions before this application being confirmed.<br/> &nbsp;&nbsp; &nbsp;&nbsp;&nbsp;I/We decalre that the above answers are full, completed and true and agree that they shall form part of my/our applition which &nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;shall be the basis of the contract of insurance.<br/> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;I/We understood that according to my/our health condition, the premium for me/us may be higher than the standard premium<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;of the plan. " 
                        oncheckedchanged="cbAgree_CheckedChanged" />
                </td>
            </tr>
            <tr>
                <td>
                    <asp:Button ID="btnSubmit" runat="server" Text="Submit Application" 
                        onclick="btnSubmit_Click" />
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                    <asp:Button ID="btnReset" runat="server" Text="Reset Information" />
                </td>
            </tr>
        </table>
        <br/>
      
    </fieldset>
    <br/>
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